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Vol. 30 -- December #12, 2011
1026
Continuing Professional Development
The articles in this series are independently researched and compiled by PSA commissioned authors and peer reviewed.
Post-hospital discharge home medicines
review: Proof of concept (n=1)
By Dr Mark Naunton
medication review
Recent (~1 month before
hospitalisation) laboratory results
available (included in the referral):
• Total cholesterol 1.9 mmol/L
• LDL 0.9 mmol/L, TG = 1.3 mmol/L
• Creatinine = 147 μmol/L (60--120
μmol/L)
• eGFR 43 mL/min/1.73 m2
• Hb = 99 g/L (130--180 g/L)
• Other biochemistry and liver tests
were reported in the normal range.
Using the Cockcroft-Gault equation,
Mr ML had a creatinine clearance of
approximately 30 mL/min.
Medication profile
The medicines listed on the GP
referral and what Mr ML reported to
be taking, as well as other medicines
used which were not on the referral,
are shown in Table 1.
Clinical assessment
Mr ML was seen by the accredited
pharmacist seven days after he was
discharged from hospital. Mr ML was
sitting in an arm chair looking tired,
unwell and short of breath. His lower
legs appeared oedematous. Mr ML
emigrated from Eastern Europe and
reported that he speaks four languages
fluently although it was not clear if
English was one of these. It became
obvious that during the interview it was
clear Mr ML had difficulty expressing
himself in English. Mr ML lived alone.
When asked about his medications Mr
ML could only show the pharmacist
the medications he was given at the
hospital at discharge (see Table 1).
During the interview, community
nursing arrived to assist Mr ML with
his medicines and assess his leg
wound. The community nurse attending
Mr ML informed the pharmacist
that there had been 'significant
changes to his medications' and that
Mr ML was only using the following:
sulphamethoxazole/trimethoprim,
oxycodone, and docusate with senna.
Dr Mark Naunton is an accredited consultant
pharmacist and community pharmacist and
Associate Professor at the University of
Canberra.
I report no conflict of interest in relation to
any of the contents of this review. Some
issues have not been discussed in detail due
to editorial restrictions.
Learning objectives
After reading this article you should
be able to:
• Describe why hospitalisation is
a critical period for medication
errors and the importance of
medication review during this
time
• Describe the risks and benefits
of warfarin therapy in atrial
fibrillation.
Competency standards (2010)
addressed:
4.1, 4.2, 7.2
Accreditation number:
CAP111212f
The pharmacist telephoned Mr ML's
GP who was unaware that his patient
had been in hospital until a request
for an HMR was received and denied
receiving any discharge summary from
the hospital. His GP asked for the
community nurse to bring Mr ML to his
practice for assessment. The pharmacist
contacted the hospital to clarify Mr ML's
medicines on discharge and provided
this list to the GP for his consultation
with Mr ML. It became clear that Mr ML
had been hospitalised for a leg infection
with changes to his pain management
(buprenorphine ceased and oxycodone
commenced) and the addition of
aperients (commencement of docusate
and senna).
Major review issue
Drug-related problems which required
attention included:
1. confusion between the hospital
and community nursing/pharmacy
and between the hospital and GP
surrounding changes to medication
at discharge (accidental cessation
of chronic medications). Specifically,
the HMR referral indicated the
patient was using more than five
medicines and the community nurse
indicated he was only using four
medicines;
2. low adherence to prescribed
antibiotic regimen (8 tablets used --
expected 14);
3. consideration for warfarin treatment
(CHADS2 score = 1);
4. dose reduction of atorvastatin due
to very low total cholesterol;
5. consideration to reduce amiodarone
dose due to low body fat;
6. treatment of anaemia.
Post-discharge medication
management
The transition between hospital
and community is a critical period
for patients. It is well recognised
that the management of medicines
among patients recently discharged
from hospital care is sub-optimal
Case details
Mr ML, 77 years old, was referred for
a home medicines review (HMR) by
his general practitioner (GP) because a
pharmacist at the hospital sent a HMR
request to the GP citing the following:
• medications changed significantly in
hospital
• new medications started in hospital
• suspected difficulty in managing
medications
• one medication with a narrow
therapeutic index
• taking five or more medications
• taking more than 12 doses per day.
Mr ML's past medical history included:
• stable vascular disease
• NSTEMI (2008)
• atrial fibrillation (2006)
• hypothyroidism (2007)
• osteoarthritis (knees)
• chronic renal failure.